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John’s going forward but may be argument in Ireland to use Rituximab first line for moderate to severe pemphigus as per European guidelines Initial skin care: Topical agents Antiseptic soap substitute if erosions present - Octenisan wash once daily (avoid Dermol 500 which is often used in UK due to increased irritant reactions) Face - Moderate potency steroids (eg eumovate) Body - Potent/super potent steroids (eg dermovate) Oral agents Betamethasone Solution: Betamethasone 500mcg tablet dissolved in 10-20ml water Use as mouthwash for 5 minutes up to QDS Do not swallow Flixonase Nasules: Fluticasone propionate 400mcg contents in 10-20ml water Mouthwash for 5 minutes up to QDS Dermovate in Orobase Gel: Apply directly to affected areas Better for deeper, persistent lesions Candida Prevention: Add 1ml nystatin to steroid mouthwashes OR use standard antifungal therapy Low threshold for treating oral candida Systemic therapies for pemphigus: Systemic Corticosteroids: BAD Guidelines: Up to 1.5mg/kg daily St

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The mechanism appears to involve preserving nitric oxide signaling and reducing neuroinflammation in damaged brain tissue